What is the best treatment plan for asthma?

Asthma Management

The best treatment plan for asthma combines inhaled corticosteroids as the foundation of daily controller therapy with short-acting beta-agonists for symptom relief, using a stepwise approach that escalates to combination therapy with long-acting bronchodilators when needed.

Initial Assessment and Severity Classification

Before initiating treatment, assess asthma severity using objective measurements 1:

• Peak expiratory flow (PEF) as percentage of predicted or personal best
• Respiratory rate (normal <25 breaths/min)
• Heart rate (normal <110 beats/min)
• Ability to speak in complete sentences

Critical warning: Underuse of corticosteroids is a major factor contributing to preventable asthma deaths, and both clinicians and patients frequently fail to appreciate disease severity 1, 2.

Controller Therapy: The Foundation

Inhaled Corticosteroids (ICS)

Inhaled corticosteroids must be the cornerstone of maintenance therapy for persistent asthma 3, 4. These are the most potent anti-inflammatory agents available and should be prescribed to all patients with persistent symptoms 4.

• Start with daily ICS for any patient requiring more than occasional reliever medication 3, 4
• Proper inhaler technique must be checked and recorded at each visit 1, 2
• Patients should remain on discharge medication for at least 24 hours before any changes 1

Combination Therapy

When ICS alone provides insufficient control, add a long-acting beta-agonist (LABA) 3, 4, 5:

• Combination ICS/LABA therapy (such as fluticasone/salmeterol) improves lung function and symptoms better than ICS alone 5
• Never use long-acting beta-agonists as monotherapy—this is inappropriate and potentially dangerous 4
• Single maintenance and reliever therapy (SMART) using ICS/formoterol is preferred for adults and adolescents because it reduces severe exacerbations 3, 6

Reliever Therapy

Short-Acting Beta-Agonists (SABA)

SABAs should never be used alone without ICS coverage 6:

• Nebulized albuterol 2.5 mg (or salbutamol 5 mg) or terbutaline 10 mg for acute symptoms 1, 7
• Onset of action within 5 minutes, with peak effect at 1 hour and duration of 3-6 hours 7
• Usual dosing is three to four times daily as needed 7
• Warning: Excessive use of inhaled sympathomimetic drugs has been associated with fatalities 7

Modern Reliever Strategy

Recent evidence supports ICS-containing reliever medication over SABA alone 6:

• ICS/formoterol as needed is superior to SABA alone for preventing severe exacerbations 6
• This approach addresses the common problem of patients reverting to SABA-only use when they stop taking maintenance ICS 6

Stepwise Treatment Algorithm

Mild Asthma

• Option 1: Maintenance low-dose ICS plus as-needed SABA 3, 4
• Option 2: As-needed ICS/formoterol (preferred to prevent non-adherence to maintenance therapy) 6

Moderate Asthma

• Increase ICS dose or add LABA to create combination therapy 3, 4
• Consider adding long-acting muscarinic antagonists (e.g., tiotropium) if needed 3, 4
• Leukotriene receptor antagonists are an alternative add-on option 3

Severe Asthma

• Maximize combination ICS/LABA therapy 8, 4
• Refer to asthma specialist for consideration of biologic agents (omalizumab, mepolizumab, reslizumab) for severe allergic or eosinophilic asthma 3, 4
• Identify and address comorbidities and risk factors 8

Acute Exacerbation Management

Moderate Exacerbation (PEF >50% predicted)

• Nebulized SABA (albuterol 5 mg or terbutaline 10 mg) 1
• Prednisolone 30-60 mg orally 1
• Reassess after 15-30 minutes 1
• If PEF improves to >75%, step up usual treatment and arrange follow-up within 48 hours 1

Severe Exacerbation (PEF <50% predicted, unable to complete sentences, pulse >110, respirations >25)

• High-flow oxygen 40-60% 1
• Nebulized SABA every 30 minutes if not improving 1
• Prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1
• Add ipratropium 0.5 mg to nebulizer, repeat every 6 hours 1
• Strongly consider hospital admission if more than one severe feature present 1

Life-Threatening Features Requiring ICU Transfer

• Silent chest, cyanosis, feeble respiratory effort 1
• Bradycardia, hypotension, confusion, exhaustion, or coma 1
• Deteriorating PEF despite treatment 1

Monitoring and Follow-Up

Regular monitoring is essential to prevent deterioration 2:

• Check inhaler technique at every visit 1, 2
• Monitor PEF variability (goal: <25% diurnal variation) 1, 2
• Follow-up within 1-4 weeks after treatment changes 2
• Patients should have their own PEF meter and written self-management plan 1

Discharge Criteria After Hospitalization

• On discharge medication for 24 hours with verified inhaler technique 1
• PEF >75% of predicted or personal best 1
• Prescribed oral steroids plus inhaled steroids and bronchodilators 1
• GP follow-up within 1 week and specialist follow-up within 4 weeks 1

Critical Pitfalls to Avoid

• Never prescribe SABA as monotherapy without ICS—this increases exacerbation risk 6
• Never use LABA without ICS—this is dangerous and inappropriate 4
• Do not underestimate severity—delay can be fatal, and attacks in the afternoon/evening warrant lower threshold for admission 1
• Recognize treatment failure early—if a previously effective regimen stops working, this signals seriously worsening asthma requiring immediate reassessment 7